Test Integumentary System and Wounds 1 Flashcards

A patient with lower extremity wounds has an ankle-brachial index (ABI) of 0.45. Which clinical decision is MOST appropriate based on this finding?

Answer: Withhold compression therapy due to severe arterial insufficiency

An ABI below 0.5 indicates severe arterial insufficiency. Compression therapy is contraindicated because it would further impede already critically reduced arterial perfusion, risking tissue ischemia and limb loss.

A burn wound presents with an intact or ruptured blister, a moist red surface, extreme pain, and blanching with direct pressure. Which burn depth classification BEST describes this injury?

Answer: Superficial partial-thickness (second-degree) burn

Superficial partial-thickness burns destroy the epidermis and superficial dermis, producing blisters, a moist weeping surface, intense pain (nerve endings intact), and blanching under pressure. Deep partial-thickness burns are less painful because deeper dermal nerve endings are damaged.

Which method of wound debridement is considered LEAST selective and carries the highest risk of removing viable granulation tissue along with necrotic material?

Answer: Mechanical debridement with wet-to-dry gauze dressings

Wet-to-dry dressing changes are a non-selective mechanical debridement technique: the gauze adheres to both necrotic and viable tissue and removes both indiscriminately when pulled away, potentially damaging new granulation tissue.

A pressure injury is assessed and found to expose bone at the wound base. A bone biopsy is ordered to rule out osteomyelitis. According to the NPUAP/EPUAP classification system, what stage is this wound?

Answer: Stage IV

Stage IV pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. The depth extends through all skin layers into supporting structures, placing the patient at high risk for osteomyelitis and septicemia.

During wound assessment, a physical therapist inserts a sterile cotton-tipped applicator at the wound margin and advances it 4 cm in a narrow, distinct channel before meeting tissue resistance. This finding is BEST documented as:

Answer: Tunneling

Tunneling (also called a sinus tract) is a narrow, channel-like extension from the wound base or edge that travels in one direction. Undermining, by contrast, is a broad, shelf-like area of tissue destruction beneath the wound edges measured circumferentially around the wound.

A patient presents with a shallow wound on the medial aspect of the lower leg with irregular edges, copious serous drainage, periwound edema, and brown hemosiderin staining of the surrounding skin. Which wound etiology is MOST consistent with this presentation?

Answer: Venous stasis ulcer

Venous stasis ulcers classically occur on the medial lower leg near the gaiter area, are shallow with irregular borders, produce heavy serous exudate, and cause hemosiderin staining from red blood cell extravasation due to chronic venous hypertension. Arterial ulcers are typically punched-out, painful, and located distally.